National Hip Fracture Database Anaesthesia Sprint Audit of Practice (ASAP) Falls and Fragility Fracture Audit Programme National Hip Fracture Database Anaesthesia Sprint Audit of Practice 2014

Prepared on behalf of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians by the ASAP collaboration team:

Chris Boulton, NHFD project manager Colin Currie, former NHFD clinical lead, orthogeriatrics Richard Griffiths, consultant anaesthetist, Peterborough and Stamford Hospitals Mike Grocott, director, National Institute of Academic Anaesthesia, Health Services Research Centre Antony Johansen, NHFD clinical lead, orthogeriatrics Amer Majeed, consultant anaesthetist, Central Manchester University Hospitals Iain Moppett, consultant anaesthetist, Nottingham University Hospitals Karin Pappenheim, executive director, Association of Anaesthetists of Great Britain & Ireland Fay Plant, NHFD project coordinator Jonathan Roberts, web developer, Crown Informatics Rob Wakeman, NHFD clinical lead, orthopaedic surgery Stuart White, consultant anaesthetist, Brighton & Sussex University Hospitals Andy Williams, NHFD project coordinator

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Copyright © Healthcare Quality Improvement Partnership 2014

Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk Registered Charity No 210508 Contents

Executive summary 5 Anaesthetic Sprint Audit of Practice standards 6 Key findings 6 Key recommendations 7

Introduction 8

Background 9

Methods 11

Key to participating hospitals 12

Findings 15 Ascertainment of cases 15 Patient characteristics 16 Comorbidities 17 Standard 1: Patients should be anaesthetised by a consultant or specialist with similar clinical experience. 18 Standard 2: Spinal/epidural anaesthesia should be considered for all patients 20 Standard 3: Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down) 22 Standard 4: Co-administration of intrathecal opioids should be restricted to fentanyl 24 Standard 5: If sedation is required this should be midazolam or propofol 26 Standard 6: Supplemental oxygen should always be provided 28 Standard 7: Inhalational agents should be considered for the induction of general anaesthesia 30 Standard 8: Spontaneous ventilation should be used in preference to mechanical ventilation 32 Standard 9: Consider intraoperative nerve blocks for all patients undergoing surgery 34 Standard 10: Neuraxial and general anaesthesia should not be combined 36 Standard 11: Hypotension should be avoided 38 Standard 12: Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome (BCIS) 42

Conclusion 44

Future work 45

Appendix 1 46 Appendix 2 47 References 59 Executive summary

Hip fracture is the commonest reason for a frail older person to need an anaesthetic and operation.

Its outcome serves as a marker of the quality of hospital care across the many disciplines and departments who will collaborate before, during and after this operation. However, the immediate physiological stress experienced by these patients is the pain and blood loss associated with the fracture. High quality anaesthetic care is crucial to the effective management of both stresses.

The aim of this Anaesthetic Sprint Audit of Practice (ASAP) was to profile individual hospitals’ compliance with standards for peri-operative care described in the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline *The Management of Proximal Femoral Fracture*.

We aimed to prospectively collect data on all patients aged over 60 who underwent hip fracture surgery in hospitals across England, Wales and Northern Ireland between 1 May and 31 July 2013.

Data for 16,904 patients treated for a hip fracture in 182 hospitals were submitted to the NHFD.

Nearly all patients (97.6%) underwent anaesthesia and operation.

Data for 80% of these patients were collected by teams including anaesthetists in each hospital, and submitted using the existing online reporting system of the National Hip Fracture Database (NHFD).

Twelve hospitals (CHE, CHS, HIN, NOB, NTH, OHM, PET, RFH, SCA, SHH, UCL and WDH) submitted ASAP data on every patient in their NHFD submission, and 95 hospitals submitted data on over 80% of their patients. A detailed analysis was based on these 11,130 (67.5%) cases in hospitals with high case ascertainment with the objective of describing current practice and variation in care – to inform the ongoing development of an consensus regarding best anaesthesia practice.

Hospitals which returned a lower proportion of cases were excluded from this analysis, to maximise its reliability. However, data for all but 23 hospitals (who did not participate in ASAP) are reported so that clinicians and managers in individual departments and hospitals can review their performance against the ASAP standards, and against that of other units in their region and throughout England, Wales and Northern Ireland (Appendix 2). Anaesthetic Sprint Audit of Practice standards

Based on the guideline *The Management of Proximal Femoral Fracture*, Association of Anaesthetists of Great Britain and Ireland, 2012

| Standard | Description | |----------|-------------| | Standard 1 | Patients should be anaesthetised by a consultant or specialist with similar clinical experience. | | Standard 2 | Spinal/epidural anaesthesia should be considered for all patients | | Standard 3 | Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down) | | Standard 4 | Co-administration of intrathecal opioids should be restricted to fentanyl | | Standard 5 | If sedation is required this should be midazolam or propofol | | Standard 6 | Supplemental oxygen should always be provided | | Standard 7 | Inhalational agents should be considered for the induction of general anaesthesia | | Standard 8 | Spontaneous ventilation should be used in preference to mechanical ventilation | | Standard 9 | Consider intraoperative nerve blocks for all patients undergoing surgery | | Standard 10 | Neuraxial and general anaesthesia should not be combined | | Standard 11 | Hypotension should be avoided | | Standard 12 | Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome |

Key findings

Where the seniority of both the surgeon and the anaesthetist present in theatre was recorded, it is encouraging to find that in over 90% of cases both were consultants or specialists, and that in only 0.4% of cases were both unsupervised trainees. However, we cannot exclude the possibility of an element of reporting bias here and there certainly remains substantial inter-hospital variation in the seniority of staff dealing with these high-risk cases.

Pain relieving nerve blocks were administered to 56% of patients. This indicates an impressive adoption of this technique during recent years, particularly since its recommendation in the 2011 NICE Guidance on Hip Fracture. However in this audit, nearly half of patients still do not receive a nerve block. The marked variation in provision of nerve blocks between different hospitals could suggest that this is more a reflection of organisational differences, than of individual patient need or preference.

There was striking inter-hospital variation in the proportion of patients being given spinal and general anaesthesia. Some units administered spinal anaesthesia in over 80% of cases, while others used this approach in less than 10%. This would suggest that the mode of anaesthesia is often determined by local departmental or individual anaesthetist preference, rather than being a response to the needs, comorbidities and preferences of individual patients. Considerable inter-hospital variation is similarly noted in the use of intrathecal opioids, of sedation, of supplemental oxygen, and in the dose of hyperbaric bupivacaine administered during spinal anaesthesia.

Despite the seniority of anaesthetic expertise, the prevalence of low blood pressure during hip fracture surgery is a major concern. Relative hypotension (systolic BP reduction >20% from pre-operative value) occurred in 89% of patients, and absolute hypotension (lowest intraoperative systolic BP \<100 mmHg) in 77%. Hypotension was consistently less prevalent among patients receiving spinal anaesthesia, compared to those receiving general anaesthesia.

Finally, ASAP supports previous work indicating that Bone Cement Implantation Syndrome (BCIS) is not uncommon after the insertion of cemented prostheses. Possible BCIS events were recorded in 19% of cases, with reactions involving severe hypoxia and/or hypotension, or cardiovascular collapse in 2.7% and 0.5% of operations respectively.

**Key recommendations**

These recommendations highlight the areas where ASAP identified substantial variation in practice against those standards for which evidence base is most robust.

- Peri-operative nerve blocks should be offered to all patients who suffer hip fracture [Standard 9]
- The reduced incidence of hypotension observed with spinal anaesthesia supports the AAGBI recommendation that this approach should be considered for all cases. [Standard 2]
- Departments of anaesthesia should develop evidence based standardized approaches to spinal anaesthesia, to reduce inconsistency in the dose of bupivacaine, and in the administration of sedatives, oxygen and intrathecal opioids. [Standards 3,4,5, and 6]
- Departments of anaesthesia should develop protocols to raise awareness of Bone Cement Implantation Syndrome and specific training for its recognition, avoidance and management. [Standard 12]

The AAGBI plans to hold a series of meetings to promote the findings of the ASAP audit. Those involved in collecting the data will be asked to share examples of good practice with other departments. There will be a dedicated ASAP session at the Annual Congress of the AAGBI in Harrogate in 2014. This will be recorded for the video library of the AAGBI. This will enable all members to see the results and presentation of the data.

These ASAP findings need to be linked to the NHFD outcome measures – so that continuation of this work can establish whether outcome is affected by the anaesthetic approach, by hypotension during surgery, or by Bone Cement Implantation Syndrome.

We believe that the level of participation in ASAP demonstrates that a collaborative approach to data collection by local teams including an anaesthetist can improve the scope and integrity of data submitted to NHFD. Consideration should be given to inclusion of key fields such as anaesthetist seniority and occurrence of hypotension when planning future development of the NHFD dataset. Introduction

Hip fracture is the commonest reason for a frail older person to need surgery and anaesthesia.

The average age of people sustaining a hip fracture is 83 years. One in six of the UK population is aged over 65 years, and the rapidly expanding over 85 year old age group already numbers half a million people. The age-specific risk of suffering a hip fracture is reducing, but the total number of cases continues to rise in line with expansion of this age group.

In the UK, hip fracture is estimated to carry an annual health and social care cost of one and a half billion pounds. Patients recovering from this injury occupy 4,000 NHS beds at any one time.

The 2013 annual report of the National Hip Fracture Database (NHFD) identified that 8.2% of patients died within 30 days of hip fracture, and that only 46.2% of those admitted from home were able to return there within the same time period.

Surgical management of hip fracture is the default treatment, as it ensures effective analgesia and facilitates rehabilitation thus reducing the risk of complications related to immobility.

The last half a century has seen a quest to identify the best anaesthetic practices to improve survival and reduce morbidity in these patients. Randomised controlled trials in this area have suffered from serious design, implementation and recruitment difficulties. Large-scale audits have the potential to explore links between structure and process measures and outcome, through comparison of data on large numbers of patients between different centres.

Collaboration between the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the National Hip Fracture Database (NHFD), led to the development and completion of the Anaesthesia Sprint Audit of Practice (ASAP). This document reports the results and analysis of this project, and attempts to provide a picture of current approaches to peri-operative care across England, Wales and Northern Ireland. Background

The rehabilitation of frail elderly patients with hip fractures was pioneered in the 1940s by Cosin. Successful surgeon-physician collaboration between Devas and Irvine in the 1960s revolutionised the care and outcomes of these patients. However, in 2000, the Audit Commission published a follow up to their 1995 report *United They Stand*[^6][^11], which identified the high prevalence of severe inadequacies in the management of hip fracture patients.

In 2001 the National Service Framework for Older People[^12] encouraged close cooperation between surgeons, anaesthetists and geriatricians in the care of these patients. In 2007 the British Geriatrics Society (BGS) and British Orthopaedic Association (BOA) collaborated in writing the ‘Blue Book’[^13], to set standards for the hip fracture patient care.

At the same time they established the NHFD, which is the largest hip fracture database in the world. This includes surgical and mortality data on a third of a million patients. It captures 95% of all cases of hip fracture, collects data from all hospitals in England, Wales, Northern Ireland and the Channel Islands, and provides an ideal infrastructure for large audits.

The Scottish Intercollegiate Guidelines Network (SIGN), and the National Institute for Health and Care Excellence (NICE) have also issued clinical guidelines[^14][^2] which reinforce the Blue Book’s message. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) publication of *An Age Old Problem*[^15] in 2010 advanced the issue higher on the government agenda.

The NHFD is a component of the Falls and Fragility Fracture Audit Programme (FFFAP), managed by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians (RCP). The work is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).

During the same period, evidence was growing indicating how anaesthetic management influences outcomes in these patients[^16][^17][^18][^19][^20]. Clinicians interested in promoting better anaesthetic management of these patients established the Hip Fracture Anaesthesia Network (HIPFAN) in 2007, and this was renamed to Hip Fracture Perioperative Network (HipPeN) in 2011.

The network produced its first report in 2010 highlighting wide variations in anaesthetic practice[^21]. It has since completed several projects enquiring into existing anaesthetic practices, and into the management and consequences of key perioperative issues such as anaesthetic technique, blood transfusion, and hypotension. These developments led to publication of the AAGBI guidelines on the anaesthetic management of the hip fractures[^1] in 2012.

A number of anaesthetists were part of the collaboration that developed the Blue Book, but anaesthetic management was not specifically addressed by the six standards set in the Blue Book[^13], and as a result the initial NHFD dataset did not attempt to profile details of anaesthetic care. In 2011 HipPeN and NHFD developed a dataset that would allow eight new anaesthetic fields to be incorporated into the NHFD.

Later in the same year the Anaesthetic Sprint Audit of Practice (ASAP) was planned and a project steering group of representatives from the NHFD, the AAGBI and the National Institute of Academic Anaesthesia (NIAA) Health Services Research Centre was established. Methods

The aim of the audit was to profile individual hospitals’ compliance with the guidelines for peri-operative care set by the AAGBI(^1) in 2012, and we set out to collect data on all patients over the age of 60 years, who underwent hip fracture surgery between 1(^{st}) May and 31(^{st}) July 2013.

An audit data set was agreed for this purpose, and after pilot studies in 2012 a final data collection sheet was agreed (Appendix 1).

Each of the 182 hospitals which routinely contribute to the NHFD was invited to form a local team comprising of trauma anaesthetists, coordinators, nurses and local NHFD representatives. The composition of a team varied from place to place.

The teams liaised with colleagues involved in trauma anaesthesia to encourage audit form completion by the attending anaesthetist(s) for every case of hip fracture surgery. They oversaw inputting of the data from completed forms into the NHFD’s online data collection tool, with online data entry completed by 27 September 2013.

Staff responsible for uploading the data were registered for each site, and secure access was granted through the NHFD lead clinician for each site. Use of the NHFD’s pre-existing website, with its security and confidentiality safeguards simplified the handling of anonymised data in respect of such a large number of patients.

Data were collected and processed with specific approval of the Secretary of State for Health on the recommendation of the Health Research Authority (HRA) Confidentiality Advisory Group (CAG)(^2) under the Health Service (Control of Patient Information) Regulations 2002. This is more commonly referred to as section 251 approval and references to ‘section 251 support or approval’ actually refer to approval given under the authority of the Regulations.

Section 251 was established to enable the common law duty of confidentiality to be overridden to enable disclosure of confidential patient information for medical purposes, where it was not possible to use anonymised information and where seeking consent was not practical, having regard to the cost and technology available.

Personal confidential data items for this audit were processed by Crown Informatics under section 251 approval prior to anonymisation and transfer to Brighton & Sussex University Hospitals NHS Trust for analysis. Reported data and data files released under government transparency guidance(^3) are managed in line with UK statistics authority guidance on the handling of small numbers(^4) to prevent the identification of individuals. Data for English hospitals included in all provider level charts in this report can be found at http://www.data.gov.uk/ Key to participating hospitals

- Hospitals which contributed data on over 80% of cases – and were therefore eligible for inclusion in the charts used to defining current patterns of anaesthesia practice, and in tables of individual performance (appendix 2)

- Hospitals which contributed data to the overall report but captured less than 80% of patients – and were therefore reported in tables of individual performance (appendix 2)

- Non participating hospitals

ADD Addenbrooke’s Hospital, Cambridge AIR Airdale General Hospital RED Alexandra Hospital, Redditch Altnagelvin Hospital WIR Arrowe Park Hospital, Wirral BNT Barnet Hospital BAR Barnsley Hospital BAS Basildon and Thurrock University Hospital BSL Bassetlaw Hospital Bedford Hospital EBH Birmingham Heartlands Hospital BRD Bradford Royal Infirmary BRI Bristol Royal Infirmary BRG Bronglais Hospital, Aberystwyth BFH Broomfield Hospital, Chelmsford CHS Chase Farm Hospital WES Chelsea and Westminster Hospital Cheleton General Hospital CHE Chesterfield Royal Hospital COL Colchester General Hospital Conquest Hospital, Hastings COC Countess of Chester Hospital HCH County Hospital, Hereford CRG Craigavon Hospital, Portadown MAY Croydon University Hospital, London CMI Cumberland Infirmary, Carlisle DVH Darent Valley Hospital, Dartford DAR Darlington Memorial Hospital DER Derbyshire Royal Infirmary, Derby PLY Derriford Hospital, Plymouth GGH Diana Princess of Wales Hospital, Grimsby DID Doncaster Royal Infirmary, WDH Dorset County Hospital, Dorchester Ealing Hospital East & North Hertfordshire Hospital ESU East Surrey Hospital, Redhill DGE Eastbourne Hospital FRY Frenchay Hospital, Bristol FRM Frimley Park, Camberley FGH Furness General Hospital, Barrow-in-Furness NUN George Eliot Hospital, Nuneaton CLW Glan Clwyd Hospital, Rhyl GLO Gloucestershire Royal Hospital, Gloucester GHS Good Hope Hospital, Birmingham GRA Grantham and District Hospital GWI Gwynedd Ysbyty, Bangor HAR Harrogate District Hospital HIL Hillingdon Hospital HIN Hinchingbrooke Hospital HOM Homerton Hospital, London SLF Hope Hospital, Salford HOR Horton Hospital, Banbury HUD Huddersfield Royal Infirmary Hull Royal Infirmary IPS Ipswich Hospital SCM James Cook University Hospital, Middlesbrough JPH James Paget University Hospital, Great Yarmouth RAD John Radcliffe Hospital, Oxford KGH Kettering General Hospital KCH King’s College Hospital, London KMH King’s Mill Hospital, Sutton in Ashfield KTH Kingston Hospital LGI Leeds General Infirmary LER Leicester Royal Infirmary Leighton Hospital, Crewe LIN Lincoln County Hospital LDH Luton and Dunstable Hospital MAC Macclesfield General Hospital WRX Maeror Hospital, Wrexham MRI Manchester Royal Infirmary Manor Hospital, Walsall MDW Medway Maritime Hospital MKH Milton Keynes General Hospital MOR Morriston Hospital, Swansea MPH Musgrove Park Hospital, Taunton NEV Nevill Hall Hospital, Abergavenny NCR New Cross Hospital, Wolverhampton | Key to participating hospitals | |--------------------------------| | NWG | Newham General Hospital, London | | NOB | Nobles Hospital, Isle of Man | | NOR | Norfolk and Norwich University Hospital | | NDD | North Devon District Hospital, Barnstaple | | NHH | North Hampshire Hospital, Basingstoke | | NGM | North Manchester General Hospital | | NTH | Northampton General Hospital | | NGS | Northern General Hospital, Sheffield | | NPH | Northwick Park Hospital, London | | PET | Peterborough District Hospital | | PIL | Pilgrim Hospital, Boston | | PIN | Pinderfields General Hospital, Wakefield | | PGH | Poole General Hospital | | PCH | Prince Charles Hospital, Merthyr Tydfil | | POW | Princess of Wales Hospital, Bridgend | | BRO | Princess Royal University Hospital, Bromley | | QAP | Queen Alexandra Hospital, Portsmouth | | QEB | Queen Elizabeth Hospital, Birmingham | | QEG | Queen Elizabeth Hospital, Gateshead | | QKL | Queen Elizabeth Hospital, King's Lynn | | QEQ | Queen Elizabeth the Queen Mother Hospital, Margate | | BRT | Queens Hospital, Burton upon Trent | | ROT | Rotherham District General Hospital | | AEI | Royal Albert Edward Infirmary, Wigan | | RBE | Royal Berkshire Hospital, Reading | | BLA | Royal Blackburn Hospital | | BOL | Royal Bolton Hospital | | RDE | Royal Devon & Exeter Hospital, Exeter | | RFH | Royal Free Hospital, London | | RGH | Royal Glamorgan Hospital, Llantrisant | | GWE | Royal Gwent Hospital, Newport | | RHC | Royal Hampshire County Hospital, Winchester | | RLU | Royal Liverpool University Hospital | | OHM | Royal Oldham Hospital | | RPH | Royal Preston Hospital | | RSS | Royal Shrewsbury Hospital | | RSU | Royal Surrey County Hospital, Guildford | | RSC | Royal Sussex County Hospital, Brighton | | BAT | Royal United Hospital, Bath | | RYN | Royal Victoria Infirmary, Newcastle | | RUS | Russells Hall Hospital, Dudley | | SAL | Salisbury District Hospital | | SAN | Sandwell General Hospital | | SCA | Scarborough General Hospital | | SCU | Scunthorpe General Hospital | | STD | South Tyneside District Hospital, South Shields | | SGH | Southampton General Hospital | | SEH | Southend Hospital | | GEO | St George's Hospital, London | | SHC | St Helier Hospital, Carshalton | | SPH | St Peter's Hospital, Chertsey | | STR | St Richard's Hospital, Chichester | | STH | St Thomas' Hospital, London | | STM | St. Mary's Hospital, Paddington | | SHH | Stepping Hill Hospital, Stockport | | SMV | Stoke Mandeville Hospital, Aylesbury | | SUN | Sunderland Royal Hospital | | TGA | Tameside General Hospital, Manchester | | PMS | The Great Western Hospital, Swindon | | PAH | The Princess Alexandra Hospital, Harlow | | RCH | The Royal Cornwall Hospital, Truro | | LON | The Royal London Hospital | | TOR | Torbay District General Hospital | | NUH | Ulster Hospital, Belfast | | UCL | University College Hospital London | | STO | University Hosp. of North Staffordshire, Stoke on Trent | | FAZ | University Hospital Aintree | | UHC | University Hospital Coventry | | DRY | University Hospital Of North Durham, Darlington | | NTG | University Hospital of North Tees, Stockton on Tees | | UHW | University Hospital of Wales, Cardiff | | LEW | University Hospital, Lewisham | | UHN | University Hospital, Nottingham | | VIC | Victoria Hospital, Blackpool | | ASH | Wansbeck Hospital | | WDG | Warrington Hospital | | LON | The Royal London Hospital | | WAT | Watford General Hospital | | WMU | West Middlesex University Hospital, Isleworth | | WSH | West Suffolk Hospital, Bury St. Edmunds | | WGH | Weston General Hospital, Weston-Super-Mare | | WEX | Wexham Park Hospital, Slough | | WHC | Whips Cross University Hospital | | WHI | Whiston Hospital, Prescot | | WHT | Whittington Hospital, London | | WHH | William Harvey Hospital, Ashford | | WYB | Withybush Hospital, Haverford West | | WRC | Worcestershire Royal Hospital, Worcester | | WRG | Worthing & Southlands Hospital | | WYT | Wythenshawe Hospital, Manchester | | YEO | Yeovil District Hospital | | YDH | York Hospital | Findings

Ascertainment of cases

During the three-month ASAP study period routine NHFD data entry continued as normal in all 182 hospitals in England, Wales and Northern Ireland. This identified 16,904 patients that were treated for a hip fracture and 16,498 that underwent surgery between 1 May and 31 July 2013.

ASAP data were submitted for 11,186 (67.8%) and analysed for 11,130 (67.5%) of these operations.

The median case ascertainment rate (the percentage of patients undergoing hip fracture surgery for whom ASAP data were submitted) was 80.6% (interquartile range 51.2 – 92.4% [range 0–100%]).

Twelve hospitals (6.5%) achieved a 100% case ascertainment rate – CHE, CHS, HIN, NOB, NTH, OHM, PET, RFH, SCA, SHH, UCL and WDH. Twenty-three hospitals (12.5%) did not submit any ASAP data.

A key objective of ASAP was to develop a national consensus regarding the optimal anaesthetic management of patients with hip fracture. A picture of variation in practice across the country will be key to the discussion and debate that will be generated when ASAP findings are reported to anaesthetists at national, regional and local scientific and clinical governance meetings over the coming year.

To minimise the effect of selective reporting the charts that illustrate key findings were therefore based on those hospitals which provided the most complete data. 95 hospitals (51.6%) achieved a case ascertainment rate of greater than 80%, and these units were therefore used to develop the charts reported here.

Hospitals with less complete case ascertainment carry the potential for bias and were excluded from such analysis, though their performance against the ASAP standards is reported in detail in the regional tables (Appendix 2). Patient characteristics

The age, sex and American Society of Anesthesiologists (ASA) grade distributions of ASAP patients were similar to previously published NHFD data (table 1). Sex was recorded for 11,129 (99.9%) patients; 71.9% were female, 28.1% male. Age was reported for 11,110 (99.8%) patients. The median age of patients was 83 years (interquartile range 77–89 years [range 24–104]), with a negatively skewed distribution (figure 1). Only data for patients aged >60 years are included, in line with NHFD reports.

Table 1. Characteristics of ASAP cases. The ASA grade distribution within each 5-year age band over 60 years was similar to that of all ASAP patients.

| Characteristic | NHFD 2011/12 | NHFD 2012/13 | ASAP 2013 | |----------------|--------------|--------------|-----------| | Gender, % | | | | | Male | 26.0 | 26.8 | 28.1 | | Female | 74.0 | 73.2 | 71.9 | | Age in years, %| | | | | 60–69 | 8.3 | 8.7 | 8.8 | | 70–79 | 22.2 | 21.7 | 22.5 | | 80–89 | 48.2 | 47.4 | 46.2 | | 90+ | 21.3 | 22.1 | 22.4 | | ASA grade, % | | | | | ASA 1 | 2.4 | 2.2 | 3.0 | | ASA 2 | 30.7 | 29.7 | 30.0 | | ASA 3 | 55.1 | 55.5 | 55.1 | | ASA 4 | 11.4 | 12.2 | 11.7 | | ASA 5 | 0.4 | 0.4 | 0.2 |

Figure 1. Age distribution of ASAP cases. Comorbidities

Comorbidity data were recorded for 10,387 (93.3%) of patients; 8,752 (84.3%) of patients had at least one recorded comorbidity and 2,696 (26.0%) had three or more recorded comorbidities. The frequencies of the types of comorbidity recorded are shown in figure 2.

Figure 2. Frequency distribution of recorded comorbidities. Standard 1: Patients should be anaesthetised by a consultant or specialist with similar clinical experience.

ASAP finding: A consultant or specialist anaesthetist was present in theatre for 95% of hip fracture operations

- There was considerable national variation in the seniority of surgeons and anaesthetists recorded as present in theatre during each hip fracture operation (figure 3).

- There may be a recording bias obscuring senior involvement within the 24% of cases in which either grade of surgeon or anaesthetist were not recorded. However, it is encouraging that of the operations in which the seniority of both surgeon and anaesthetists were recorded very few (0.4%) were performed by unsupervised trainees.

- The specialist expertise of each anaesthetist relating to hip fracture care irrespective of grade was not assessed in the current project.

The grade of the most senior surgeon and the most senior anaesthetist were both recorded for 75.6% of operations. The most senior personnel present during these operations are shown in table 2, and by hospital in figure 3.

Table 2. Seniority of most senior surgeon and anaesthetist present in theatre during 8,417 hip fracture operations. Figures are given as percentages.

| Most senior anaesthetist present in theatre | Most senior surgeon present in theatre | |-------------------------------------------|---------------------------------------| | | Consultant/specialist | Trainee | | Most senior surgeon present in theatre | 91.7 | 2.9 | | Consultant/specialist | 5.0 | 0.4 | Figure 3. Grade of most senior anaesthetist and surgeon present in theatre, by hospital. Standard 2: Spinal/epidural anaesthesia should be considered for all patients

ASAP finding: Only 44% of patients were administered spinal, and only 0.2% epidural anaesthesia

- There was very striking variation across the country with some units administering spinal anaesthesia in over 80% of cases, while others used this approach in less than 10%. This suggests that the mode of anaesthesia is often determined by local departmental or individual anaesthetist preference, rather than being a response to the needs, comorbidities and preferences of individual patients.

- Questions of patient preference could not be directly addressed in our audit. We did not record whether spinal or epidural anaesthesia was “considered” by the anaesthetist and patient, but a substantial number of units were using general anaesthesia in over three-quarters of cases suggesting that this approach is routinely selected in some hospitals.

Mode of anaesthesia was recorded by NHFD data collectors for 10,876/11,130 (97.7%) patients, and by ASAP data collectors for 10,936 (98.3%) of patients. There was concordance between the mode of anaesthesia recorded by NHFD and ASAP data collectors for 7,173 (64.5%) patients.

In the ASAP recorded data, general anaesthesia (+/- nerve block/epidural) was administered to 5,640 (50.7%) of the ASAP patient group, spinal anaesthesia (+/- nerve block/epidural) to 4,916 (44.2%), and both general and spinal anaesthesia (+/- nerve block/epidural to 380 (3.4%) patients; 194 patients (1.7%) had ‘other’ anaesthesia, mainly repair under local anaesthesia (figure 4). Epidural anaesthesia was administered to 21 (0.2%) patients.

Figure 4. Modes of anaesthesia administered as a proportion of all patients with ASAP data recorded.

The mode of anaesthesia varied markedly between hospitals (figure 5). General anaesthesia was administered to between 19.6% and 92.4% of patients. Nerve blocks were administered to between 8.3% and 91.1% of patients. Figure 5. Mode of anaesthesia by hospital. Standard 3: Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down)

**ASAP finding:** Nearly 80% of patients receiving spinal anaesthesia were administered over 1.9mls (9mg) of 0.5% hyperbaric bupivacaine, the median dose being 2.5mls (12.5mg).

- Evidence suggests that lower doses of 0.5% hyperbaric bupivacaine are associated with lower degrees of relative intraoperative hypotension.
- Further work is planned to analyse this association, and to establish whether the use of lower doses of bupivacaine are associated with an increased rate of failed spinal anaesthesia, and whether the use of lower doses, or other agents (eg isobaric bupivacaine) confers benefit in terms of intraoperative blood pressure.

Spinal anaesthesia was administered to 5,638 (50.7%) patients, but failed in 342 (6.1%). The most frequently used local anaesthetic agent was 0.5% hyperbaric bupivacaine, which was administered to 3,336 (59.2%) patients receiving spinal anaesthesia.

The median volume of 0.5% hyperbaric bupivacaine administered intrathecally was 2.5mls (interquartile range 2.2–2.8 [range 0.65–4.7]), with 79.5% of patients receiving more than 1.9mls (figure 6).

**Figure 6.** Frequency distribution of volume of subarachnoid 0.5% hyperbaric bupivacaine administered. Figure 7. Proportion of patients administered spinal anaesthesia in the lateral dependent position using less than 2mls 0.5% hyperbaric bupivacaine, by hospital Standard 4: Co-administration of intrathecal opioids should be restricted to fentanyl

ASAP finding: 22% of patients successfully administered spinal anaesthesia received intrathecal fentanyl

There is very little evidence concerning the use of intrathecal opioids for hip fracture patients. Fentanyl appears to have a bupivacaine-sparing effect, reducing intraoperative hypotension, but there is no specific evidence for the use of other opioids in these patients. There is concern that higher doses of intrathecal diamorphine and morphine do not extend the duration of postoperative analgesia, but are associated with additional side-effects (postoperative confusion, respiratory depression, itching), particularly in the age group sustaining hip fracture.

In the 3,617/5,296 (68.2%) successfully administered spinal anaesthetics for which opioid co-administration was recorded, fentanyl was used in 31.9%, diamorphine in 49.7% and morphine in 3.9% (14.5% other opioid or no opioid used), but there was wide variation between hospitals in the type of opioid used (figure 8). Figure 8. Proportion of patients with spinal opioid who were administered fentanyl, by hospital. Standard 5: If sedation is required this should be midazolam or propofol

ASAP finding: Midazolam and propofol were administered as single sedative agents to around 15% and 25% of patients receiving sedation during spinal anaesthesia, respectively

- Sedation was administered to 74% of patients having spinal anaesthesia. There was marked variation between different units with sedation being given to less than a quarter of patients in some units, and to all patients in others (Figure 9).

- Over-sedation is relatively common during hip fracture repair under spinal anaesthesia, and might contribute both to intraoperative hypotension, and to postoperative confusion and delayed rehabilitation.

- The use of propofol is associated with reduced postoperative confusion when compared to benzodiazepines and opioids.

- At low doses ketamine is analgesic, but it is unclear whether it has any additional clinical analgesic benefit when spinal anaesthesia is used. At higher doses, its use is associated with postoperative confusion.

Of the 5,638 patients receiving spinal anaesthesia, 4,195 (74.4%) were sedated with one (53.6% cases), two (40.7%), three (5.4%) or four (0.3%) sedative agents.

A benzodiazepine was administered in 33.2% of cases, propofol in 29.0%, ketamine in 22.0% and an opioid in 15.9% of all those who were sedated. Information about the mode of administration (single-dose, infusion) was not collected. Figure 9. Proportion of patients receiving sedation during spinal anaesthesia, by hospital. Standard 6: Supplemental oxygen should always be provided

ASAP finding: Supplemental oxygen was administered to 71% of patients receiving sedation during spinal anaesthesia

- Age-related reductions in pulmonary gas transfer when supine suggest that supplemental oxygen should routinely be administered to patients receiving sedation, although there is little evidence to support this standard.

- Hypoxia can contribute to postoperative confusion and delayed recovery, but whether supplemental oxygen is necessary provided the arterial oxygen saturations exceeds a monitored 95% requires further investigation.

Supplemental oxygen was provided for 71.1% of patients administered sedation during spinal anaesthesia (figure 10). Figure 10. Proportion of patients administered spinal anaesthesia who were sedated and received or did not receive supplemental oxygen, by hospital. Standard 7: Inhalational agents should be considered for the induction of general anaesthesia

ASAP finding: Inhalational agents were used to induce general anaesthesia in around 5% of hip fracture patients

- General anaesthesia was administered to more than half (54.1%) of patients, although there was a marked range of prevalence between hospitals.
- Inhalational induction with sevoflurane, particularly at lower inspired concentrations, reduces mean arterial pressure less than occurs with intravenous propofol induction, and may confer greater cardiostability in this patient group.
- It remains uncertain whether it is the dose or rate of administration of inhalational or intravenous anaesthesia during induction that is of the greater importance.
- The AAGBI 2014 guidelines Peri-operative Care of the Elderly advocate the use of a Lerou nomogram (or similar dosage chart) in order to guide age-adjusted delivery of inhalational anaesthetic agents to maintain general anaesthesia (as received by 88% of patients administered GA in this audit), and so avoid relative overdose.

General anaesthesia was administered to 6,020 (54.1%) of patients. Modes of general anaesthesia induction and maintenance are summarised in table 3.

Table 3. Modes of general anaesthesia induction and maintenance. Figures are given as percentages

| | Induction of general anaesthesia | Maintenance of general anaesthesia | |----------------------|----------------------------------|-----------------------------------| | Intravenous | 93.0 | 5.4 | | Inhalational | 3.9 | 88.4 | | Intravenous and inhalational | 2.6 | 0.7 | | Not recorded | 0.5 | 6.2 | Figure 11. Proportion of inhalational/intravenous general anaesthesia induction, by hospital. Standard 8: Spontaneous ventilation should be used in preference to mechanical ventilation

ASAP finding: 44% of patients breathed spontaneously throughout general anaesthesia

- Endotracheal intubation reduces the risk of aspirating gastric contents into the lungs. Mechanical ventilation permits control of end-tidal carbon dioxide levels, but may contribute to pulmonary and systemic inflammation even if lung protective ventilation strategies are used.

- Evidence specific to the hip fracture population is very limited, and it remains uncertain whether the balance of benefits and risks favours mechanical or spontaneous ventilation.

The airway was maintained using an endotracheal tube in 44.2% and a laryngeal mask airway in 51.1% of patients administered general anaesthesia (both/not recorded 4.7%).

The mode of ventilation and degree of neuromuscular paralysis administered to patients receiving general anaesthesia are summarised in table 4.

Table 4. The mode of ventilation and degree of neuromuscular paralysis administered to patients receiving general anaesthesia. Figures are given as percentages.

| Airway device used | Endotracheal tube | Laryngeal mask airway | |-------------------------------------|-------------------|-----------------------| | Paralysed, mechanical ventilation | 81.3 | 8.6 | | Non-paralysed, mechanical ventilation| 9.1 | 13.0 | | Spontaneous ventilation | 0.0 | 73.0 | | Other | 9.3 | 5.4 |

The mode of ventilation and degree of paralysis varied considerably by hospital (figure 12), with between 2 and 93% of patients being paralysed and mechanically ventilated. Figure 12. Proportion of patients receiving general anaesthesia that were paralysed and ventilated, by hospital. Standard 9: Consider intraoperative nerve blocks for all patients undergoing surgery

ASAP finding: Nerve blocks were administered to 56% of patients.

- Most nerve blocks (54%) were administered without ultrasound-guidance or peripheral nerve stimulation. However, 56% of patients received a fascia iliaca block, which can be performed relatively safely using a non-guided landmark technique.

- There are relatively few contraindications to nerve blocks, particularly femoral nerve or fascia iliaca compartment blockade. Supplemental nerve blockade helps to control acute and perioperative pain and to reduce the need for perioperative opioid, both of which are considerations when seeking to prevent post-operative delirium.

- The administration of a functional nerve block may also avoid the use of sedation when moving a patient into the lateral or sitting position for administering spinal anaesthesia, and may reduce the volume of intrathecal bupivacaine necessary for anaesthesia.

Analgesic peripheral nerve block was administered to 6,233 (56.0%) patients; 7,332 blocks were performed. More than one block was performed in 1,073 (17.2%) patients. Peripheral blocks were established before anaesthesia in 15.5% of cases.

Ultrasound guidance only was used in 26.4% of cases, peripheral nerve stimulation only in 13.4%, both in 6.0% and neither in over half (54.1%) of patients.

The most frequently performed single peripheral nerve blocks were the fascia iliaca compartment block (55.9%) and the femoral nerve block (26.6%).

The proportion of all patients receiving a peripheral nerve block varied from eight to 92% between hospitals (figure 13). Figure 13. The proportion of all patients receiving a peripheral nerve block by hospital. Standard 10: Neuraxial and general anaesthesia should not be combined

ASAP finding: General and spinal (neuraxial) anaesthesia were given in combination to 3.4% of hip fracture patients

- Use of a combination of both spinal and general anaesthesia was associated with the highest prevalence of hypotension, possibly reflecting the combined effect of reduced heart rate, contractility and blood vessel tone in people without the reserve to cope with such stresses.

Reported rates of combined general and spinal anaesthetic varied from 0 to 25.4% across the hospitals shown in figure 14.

The combined technique is more popular for elective hip arthroplasty, which tends to be a fitter and younger patient group. Figure 11 shows that only in a small number of units is the combination technique popular. In units where only a few combined techniques were recorded, this may reflect a failed or inadequate spinal anaesthetic being converted into a general anaesthetic. Figure 14. The proportion of all patients receiving a combination of both spinal and general anaesthesia by hospital. Standard 11: Hypotension should be avoided

ASAP finding: Intraoperative hypotension occurred for the majority of hip fracture patients; in 56–89%, depending on which of several commonly used definitions was used

- Despite the widespread presence of senior anaesthetic expertise in theatre, the prevalence of intraoperative varied markedly between units. The mean prevalence of relative hypotension (systolic blood pressure reduction >20% from pre-operative value) was 90% and that of absolute (lowest intraoperative SBP \<100 mmHg) hypotension was 77%.

- Hypotension was consistently less prevalent among patients receiving spinal anaesthesia, compared to those receiving general anaesthesia.

- When interpreting these figures it is important to remember that they were derived from two single measures of perioperative BP, immediately before administration of anaesthesia and at the lowest recorded blood pressure. As a result they do not provide information about the rate of decline of blood pressure, frequency of measurement, duration of hypotension, repeated episodes of hypotension, fluid status or use of vasopressors/invasive arterial blood pressure monitoring.

- This high prevalence of hypotension indicates that this is an important area for future consideration. A consistent definition of ‘hypotension’ is urgently required.

Data were recorded for pre-induction and lowest recorded intra-operative systolic (SBP) and diastolic (DBP) blood pressures for 10,244 (92.0%) patients. Mean arterial pressures (MAP) were calculated from these data as a (third of the pulse pressure + diastolic blood pressure).

Mean (SD) pre-induction blood pressures were 147(25)/74(14) (MAP 97(16)) and lowest intraoperative blood pressure 88(18)/47(11) (MAP 60 (12)).

The mean (SD) fall in SBP for all patients in which type of anaesthesia was also known was 38(14)%, 40(14)% for patients administered general anaesthesia, 34(13)% for patients administered spinal anaesthesia and 41(13)% for patients administered general and spinal anaesthesia.

The prevalence of hypotension was analysed according to a variety of criteria, there being no commonly agreed definition of ‘hypotension’:

**Absolute values**

- Lowest intraoperative SBP < 100 mmHg
- Lowest intraoperative SBP < 90 mmHg
- Lowest intraoperative MAP < 70 mmHg
- Lowest intraoperative MAP < 55 mmHg

**Relative changes**

- SBP reduction > 20% from pre-operative value
- SBP reduction > 30% from pre-operative value
- MAP reduction > 20% from pre-operative value
- MAP reduction > 30% from pre-operative value Table 5 summarises the prevalence of hypotension according to definition and type of anaesthesia used.

| Type of anaesthesia | All | GA | GA + SA | SA | |---------------------|------|------|---------|------| | Fall SBP > 20% | 88.9 | 92.3 | 92.8 | 84.6 | | Fall SBP > 30% | 71.3 | 78.2 | 81.8 | 62.3 | | Lowest SBP < 90mmHg | 56.2 | 66.6 | 74.9 | 42.7 | | Lowest SBP < 100mmHg| 77.0 | 85.2 | 92.2 | 66.3 | | Fall MAP > 20% | 87.8 | 90.8 | 93.1 | 83.9 | | Fall MAP > 30% | 69.2 | 76.1 | 81.0 | 60.3 | | MAP < 70mmHg | 79.2 | 86.1 | 91.1 | 70.3 | | MAP < 55mmHg | 32.4 | 40.3 | 47.3 | 21.9 |

The prevalence of recorded hypotension varied from 68.3% to 100.0% for relative hypotension (figure 15) and from 36.6% to 96.2% for absolute hypotension (figure 16) between hospitals, according to the ‘least bad’ definitions of hypotension used (SBP reduction > 20% from pre-operative value, and lowest intraoperative SBP < 100 mmHg, respectively). Figure 15. Prevalence of relative hypotension (SBP reduction >20% from pre-op. value), by hospital. Figure 16. Prevalence of absolute hypotension (lowest intraoperative SBP < 100mmHg), by hospital. Standard 12: Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome (BCIS)

ASAP finding: Data about the possible occurrence of BCIS were recorded for 84% of operations in which a cemented prosthesis was inserted

- Possible Bone Cement Implantation Syndrome – shortly after cement or reaming was reported in 19% of these cases
- Possible reactions involving severe hypoxia and/or hypotension, or cardiovascular collapse, were less prevalent – occurring in 2.7% and 0.5% of operations respectively.

Cemented prostheses (hemi- or total arthroplasty) were used in 4,487/11,120 (40.4%) of recorded operations. Data about possible Bone Cement Implantation Syndrome (BCIS) reactions were recorded for 3,757 (83.7%) of these.

Possible BCIS occurred in 19.0% of operations in which a cemented prosthesis was used. The severity of the reaction was recorded as moderate (hypoxia \<94% SpO₂ or hypotension >20% fall in systolic blood pressure) in 15.8% of operations, severe (hypoxia \<88% SpO₂ or hypotension > 20% fall in systolic blood pressure or loss of consciousness) in 2.7%, and resulting in cardiovascular collapse (requiring cardiopulmonary resuscitation) in 0.5%.

The prevalence of possible BCIS was similar between patients receiving cemented hemiarthroplasty and total arthroplasty for hip fracture repair, but varied between hospitals (figure 17). Figure 17. Proportion of cemented prosthesis insertions with possible Bone Cement Implantation Syndrome reactions, by hospital. (Eligible hospitals performing less than 1 such insertion per week excluded from this chart: BNT, CHS, FGH, GHS, HIN, HOM, NOB, NTG, NWG, PCH, RBE, RGH, UCL). Conclusion

The relative contribution of anaesthesia to outcome after hip fracture repair remains uncertain, but experience across medicine suggests that better outcomes are associated with standardisation of practice.

ASAP has highlighted great variability in adherence to its standards; reflecting the paucity of high quality research in this field. A key objective of ASAP has been to define current practice – so as to develop a consensus regarding best practice. These results will help individual anaesthetists and departments of anaesthesia to understand the standards described in the AAGBI guideline.

Research in the complex, heterogeneous hip fracture population is difficult, making it difficult to formulate evidence-based guidelines. The AAGBI guidelines resulted from review of current evidence by specialists in the perioperative care of hip fracture patients. However, in some instances, the guidelines were based only on expert opinion, and ASAP standards were proposed to focus attention on an important clinical question. Until specific peer-reviewed evidence is published to the contrary, the guidelines and standards describe a minimum standard of care to which all hip fracture anaesthetists should aspire.

The ASAP dataset includes over 11,000 patients, and is the largest prospective, multicentre collection of anaesthesia-specific data about hip fracture patients ever collected. Data were entered contemporaneously by anaesthetists to improve accuracy compared to routine audit work, which normally relies on non-anaesthetists to retrospectively collate operative and anaesthetic details.

Despite the scale, and comprehensive coverage achieved in ASAP it is important not to over interpret the meaning of observational and audit data – these are not a replacement for scientific research studies that can be designed to formally test an hypothesis.

However, there are some striking findings, most notably the high prevalence of intraoperative hypotension, the limited use of nerve blockade in addition to spinal and/or general anaesthesia and the wide inter-hospital variation in type of anaesthesia administered. Furthermore, this work supports previous studies indicating that Bone Cement Implantation Syndrome is not uncommon after the insertion of cemented prostheses. Future work

Brighton and Sussex University Hospitals, who analysed data for this report are currently seeking approval for a further piece of work linking ASAP data with NHFD measures of outcome, including mortality and return to residence. This will seek to establish how the approach to anaesthesia, and the occurrence of intraoperative hypotension or BCIS might affect outcome. This work will also consider whether the Nottingham Hip Fracture Score is an accurate risk score for case-mix adjustment. The results of this extension to ASAP will be submitted for publication in a peer reviewed journal.

### Appendix 1

ASAP audit data collection sheet

#### AAGBI / BOA / BGS / NATIONAL HIP FRACTURE DATABASE

HIP FRACTURE ANAESTHESIA SPRINT AUDIT PROJECT (ASAP)–2013

| 2.01 General Anaesthesia | 2.02 Nerve block | 2.03 Spinal anaesthesia | 2.04 Injectate (freehand) | |--------------------------|------------------|-------------------------|--------------------------| | Induction | Femoral | No sedation | Spinal drug | | Maintenance | Fascia iliaca | Propofol | Bupivacaine | | Airway | Lateral Cutaneous Nerve Thigh | Ketamine | Other (name) | | Ventilation | Psoas/Lumbar Plexus | Opioid | Concentration (%) | | Muscle relaxant used? | Epidural | Concentration (%) | Baricity | | Not applicable | Local to skin | heavy | heavy | | | Peri-articular | plain | plain | | | Ultrasound guided | Opioid added... | | | | Peripheral nerve stimulator used | Other drugs added... | | | | Inserted before anaesthesia | No Drugs given | |

| 2.05 Co-morbidities | 2.06 Specialist Grade in theatre | 2.07 Bone cement implantation syndrome - shortly after cement or reaming: | |---------------------|----------------------------------|---------------------------------------------------------------------| | Active malignancy in last 20 years | Surgeon | Moderate hypoxia (SpO₂ < 94%) or hypotension (Systolic BP fall > 20%) | | Hospital admission [Hb] \<10 g/dl | Cons | Severe hypoxia (< 88%) or hypotension (Systolic BP fall > 40%) or loss of consciousness | | Previous/current MI | Operating | Cardiovascular collapse, requiring cardiopulmonary resuscitation | | Atrial fibrillation | Supervising | No problems with cement | | Valvular heart disease | Anaesthetist | | | Hypertension | Anaesthetising | | | Stroke | Supervising | | | Transient ischaemic attack | | | | Asthma | | | | COPD | | | | Renal disease | | | | Not applicable | | |

| 2.08 Intraoperative BP | | |------------------------|------------------| | Pre-induction | systolic mmHg | | | diastolic mmHg | | Lowest systolic | mmHg | | Lowest diastolic | mmHg |

## Appendix 2

| EAST MIDLANDS | CHE. Chesterfield Royal | DFR. Royal Derby Hospital | GHA. Grantham And District General Hospital | KGH. Kettering General Hospital | KMH. Kings Mill Hospital | LER. Leicester Royal Infirmary | LIN. Lincoln County Hospital | NTH. Northampton General Hospital | PIL. Pilgrim Hospital | UHN. University Hospital Queens Medical Centre | EAST MIDLANDS | ASAP | |---------------|------------------------|--------------------------|---------------------------------------------|-------------------------------|------------------------|-----------------------------|-----------------------------|-------------------------------|-----------------------------|---------------------------------|---------------|------| | Total number of ASAP cases submitted | 100 | 83 | 30 | 46 | 66 | 230 | 55 | 80 | 76 | 97 | 863 | 11186 | | Percentage of eligible cases submitted | 100 | 55 | 86 | 49 | 63 | 99 | 67 | 100 | 99 | 53 | 77 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | 52 | 74 | 100 | 72 | 58 | 57 | 83 | 73 | 93 | 61 | 72 | 62 | | Spinal or epidural anaesthesia (%) | 2 | 59 | 82 | 67 | 30 | 56 | 48 | 56 | 55 | 48 | 48 | 55 | 40 | | Less than 10mg hyperbaric bupivacaine (%) | 3 | 0 | 1 | 5 | 0 | 0 | 0 | 0 | 2 | 0 | 1 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | 8 | 76 | 5 | 0 | 24 | 11 | 40 | 0 | 11 | 24 | 20 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | 29 | 44 | 75 | 82 | 42 | 28 | 4 | 11 | 21 | 62 | 40 | 33 | | Supplemental oxygen during spinal (%) | 6 | 65 | 77 | 83 | 64 | 75 | 82 | 77 | 49 | 88 | 54 | 71 | 62 | | Inhalational agent for GA induction (%) | 7 | 2 | 7 | 0 | 6 | 7 | 5 | 0 | 8 | 6 | 12 | 5 | 4 | | Spontaneous ventilation during GA (%) | 8 | 59 | 53 | 30 | 38 | 66 | 63 | 26 | 56 | 64 | 36 | 49 | 36 | | Nerve block provided (%) | 9 | 32 | 42 | 90 | 74 | 48 | 59 | 62 | 29 | 25 | 84 | 54 | 49 | | General and neuraxial not combined (%) | 10 | 98 | 100 | 97 | 100 | 100 | 99 | 100 | 99 | 92 | 99 | 98 | 97 | | Relative hypotension (%) | 11a | 88 | 97 | 93 | 91 | 97 | 86 | 89 | 89 | 91 | 91 | 91 | 88 | | Absolute hypotension (%) | 11b | 75 | 83 | 87 | 73 | 78 | 77 | 79 | 74 | 70 | 74 | 77 | 79 | | No suggestion of possible BCIS (%) | 12 | 75 | 89 | 92 | 75 | 100 | 79 | 90 | 90 | 86 | 95 | 87 | 87 | | EAST OF ENGLAND | AOD | BAS | BED | BPH | CCL | ENH | HIN | IPS | JPH | LDH | NOR | PAH | PET | QKL | SEH | WAT | WSH | EAST OF ENGLAND | ASAP | |----------------|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|----------------|------| | Total number of ASAP cases submitted | 61 | 107 | 0 | 87 | 60 | 0 | 55 | 43 | 37 | 56 | 162 | 88 | 94 | 70 | 100 | 15 | 85 | 1120 | 11186 | | Percentage of eligible cases submitted | 60 | 99 | – | 76 | 44 | – | 100 | 36 | 34 | 97 | 72 | 95 | 100 | 69 | 93 | 14 | 93 | 64 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | 61 | 97 | – | 75 | 76 | – | 89 | 65 | 97 | 84 | 42 | 80 | 79 | 83 | 92 | 47 | 49 | 66 | 62 | | Spinal or epidural anaesthesia (%) | 2 | 21 | 36 | – | 22 | 35 | – | 57 | 49 | 71 | 48 | 44 | 65 | 48 | 60 | 32 | 27 | 28 | 38 | 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 | 8 | 11 | – | 0 | 0 | – | 0 | 0 | 0 | 0 | 2 | 0 | 0 | 3 | 0 | 0 | 1 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | 15 | 38 | – | 5 | 24 | – | 45 | 0 | 23 | 57 | 6 | 31 | 57 | 58 | 12 | 50 | 7 | 25 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | 78 | 48 | – | 55 | 32 | – | 33 | 25 | 31 | 32 | 73 | 65 | 45 | 42 | 62 | 100 | 37 | 45 | 33 | | Supplemental oxygen during spinal (%) | 6 | 89 | 84 | – | 45 | 58 | – | 43 | 75 | 50 | 60 | 84 | 70 | 18 | 32 | 85 | 100 | 63 | 56 | 62 | | Inhalational agent for GA induction (%) | 7 | 2 | 0 | – | 5 | 18 | – | 0 | 0 | 33 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 4 | 4 | | Spontaneous ventilation during GA (%) | 8 | 28 | 12 | – | 23 | 21 | – | 61 | 57 | 22 | 55 | 46 | 23 | 18 | 54 | 6 | 9 | 29 | 27 | 36 | | Nerve block provided (%) | 9 | 67 | 52 | – | 83 | 62 | – | 89 | 58 | 38 | 50 | 59 | 28 | 69 | 81 | 69 | 100 | 86 | 58 | 49 | | General and neuraxial not combined (%) | 10 | 97 | 100 | – | 94 | 100 | – | 98 | 95 | 100 | 98 | 98 | 99 | 100 | 100 | 100 | 99 | 100 | 99 | 97 | | Relative hypotension (%) | 11a | 87 | 85 | – | 92 | 96 | – | 75 | 93 | 100 | 88 | 62 | 85 | 87 | 90 | 93 | 100 | 96 | 90 | 88 | | Absolute hypotension (%) | 11b | 85 | 64 | – | 84 | 77 | – | 65 | 73 | 85 | 75 | 82 | 60 | 64 | 77 | 84 | 73 | 85 | 78 | 79 | | No suggestion of possible BCIS (%) | 12 | 81 | 74 | – | 91 | 81 | – | 100 | 93 | 78 | 88 | 93 | 16 | 77 | 73 | 70 | 89 | 93 | 82 | 87 | | LONDON | ASAP | BNT | BNU | CHS | GWH | HIL | KCH | KTH | LON | MAY | NMH | NPH | NWG | OLD | RFH | SHC | STH | STM | UCL | WES | WHC | WHT | WMU | |--------|------|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----| | Total number of ASAP cases submitted | 72 | 76 | 32 | 35 | 0 | 57 | 19 | 31 | 80 | 20 | 15 | 39 | 0 | 65 | 27 | 0 | 46 | 69 | 53 | 68 | 14 | 32 | 45 | 24 | 46 | 965 | 11186 | | Percentage of eligible cases submitted | 96 | 78 | 100 | 55 | – | 97 | 90 | 79 | 94 | 53 | 52 | 61 | – | 89 | 87 | – | 100 | 69 | 91 | 85 | 100 | 76 | 56 | 77 | 78 | 71 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | 32 | 73 | 47 | 56 | – | 68 | 53 | 73 | 38 | 35 | 53 | 51 | – | 49 | 83 | – | 43 | 91 | 75 | 44 | 50 | 31 | 60 | 38 | 67 | 49 | 62 | | Spinal or epidural anaesthesia (%) | 2 | 13 | 76 | 19 | 46 | – | 63 | 37 | 43 | 70 | 25 | 13 | 44 | – | 22 | 46 | – | 28 | 28 | 28 | 50 | 65 | 4 | 75 | 70 | 36 | 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 | 0 | 4 | 0 | 0 | – | 0 | 0 | 23 | 2 | 0 | 0 | 12 | – | 0 | 8 | – | 0 | 5 | 0 | 0 | 15 | 0 | 0 | 3 | 3 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | 42 | 9 | 57 | 25 | – | 58 | 22 | 23 | 33 | 0 | 0 | 59 | – | 50 | 62 | – | 71 | 21 | 30 | 39 | 43 | 20 | 0 | 20 | 16 | 28 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | 13 | 65 | 0 | 33 | – | 15 | 0 | 80 | 21 | 0 | 0 | 15 | – | 13 | 0 | – | 17 | 11 | 36 | 40 | 50 | 25 | 0 | 64 | 63 | 22 | 33 | | Supplemental oxygen during spinal (%) | 6 | 75 | 63 | 60 | 73 | – | 72 | 78 | 40 | 69 | 100 | 100 | 92 | – | 75 | 100 | – | 58 | 83 | 86 | 70 | 67 | 80 | 100 | 50 | 79 | 67 | 62 | | Inhalational agent for GA induction (%) | 7 | 0 | 4 | 0 | 29 | – | 0 | 0 | 5 | 0 | 0 | 17 | – | 0 | 0 | 0 | – | 3 | 0 | 0 | 0 | 14 | 0 | 0 | 0 | 0 | 3 | 4 | | Spontaneous ventilation during GA (%) | 8 | 48 | 54 | 23 | 24 | – | 58 | 8 | 5 | 27 | 0 | 7 | 29 | – | 45 | 8 | – | 18 | 24 | 18 | 41 | 29 | 33 | 14 | 0 | 7 | 21 | 36 | | Nerve block provided (%) | 9 | 75 | 28 | 91 | 57 | – | 46 | 58 | 26 | 54 | 70 | 73 | 56 | – | 40 | 8 | – | 65 | 32 | 45 | 63 | 43 | 28 | 84 | 29 | 80 | 46 | 49 | | General and neuraxial not combined (%) | 10 | 96 | 89 | 100 | 94 | – | 95 | 95 | 83 | 99 | 100 | 93 | 95 | – | 100 | 96 | – | 100 | 100 | 96 | 87 | 100 | 94 | 98 | 100 | 98 | 96 | 97 | | Relative hypotension (%) | 11a | 92 | 66 | 87 | 79 | – | 93 | 89 | 94 | 92 | 89 | 86 | 73 | – | 89 | 83 | – | 89 | 72 | 94 | 86 | 100 | 58 | 77 | 70 | 98 | 86 | 88 | | Absolute hypotension (%) | 11b | 76 | 75 | 81 | 59 | – | 70 | 79 | 80 | 78 | 60 | 46 | 76 | – | 82 | 70 | – | 69 | 85 | 96 | 70 | 92 | 65 | 81 | 86 | 78 | 78 | 79 | | No suggestion of possible BCIS (%) | 12 | 100 | 100 | 100 | 92 | – | 95 | 100 | 100 | 91 | 100 | 100 | 94 | – | 97 | 100 | – | 95 | 80 | 74 | 86 | 100 | 100 | 68 | 100 | 74 | 94 | 87 | | NORTHERN IRELAND | ALT, Altnagelvin Hospital | CRG, Craigavon Area Hospital | NUH, Ulster Hospital | RVB, Royal Victoria Hospital | NORTHERN IRELAND | ASAP | |------------------|--------------------------|-----------------------------|---------------------|-----------------------------|-----------------|------| | Total number of ASAP cases submitted | 0 | 44 | 77 | 0 | 121 | 11186 | | Percentage of eligible cases submitted | – | 73 | 93 | – | 42 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | – | 95 | 69 | – | 41 | 62 | | Spinal or epidural anaesthesia (%) | 2 | – | 48 | 14 | – | 16 | 40 | | Less than 10mg hyperbaric bupivacaine (%) | 3 | – | 0 | 0 | – | 0 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | – | 57 | 0 | – | 14 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | – | 6 | 40 | – | 11 | 33 | | Supplemental oxygen during spinal (%) | 6 | – | 61 | 70 | – | 33 | 62 | | Inhalational agent for GA induction (%) | 7 | – | 13 | 9 | – | 5 | 4 | | Spontaneous ventilation during GA (%) | 8 | – | 38 | 50 | – | 22 | 36 | | Nerve block provided (%) | 9 | – | 93 | 92 | – | 46 | 49 | | General and neuraxial not combined (%) | 10 | – | 98 | 100 | – | 99 | 97 | | Relative hypotension (%) | 11a | – | 77 | 93 | – | 92 | 88 | | Absolute hypotension (%) | 11b | – | 90 | 87 | – | 94 | 79 | | No suggestion of possible BCIS (%) | 12 | – | 76 | 94 | – | 93 | 87 | | NORTH EAST | ASAP | Wansbeck General Hospital | DAR | Darlington Memorial Hospital | DRY | University Hospital of North Durham | NTG | University Hospital of North Tyneside | NTY | North Tyneside Hospital | QEG | Queen Elizabeth Hospital, Gateshead | RVN | Royal Victoria Infirmary | SCM | James Cook University Hospital | STD | South Tyneside District Hospital | SUN | Sunderland Royal Hospital | NORTH EAST | ASAP | |-----------|------|---------------------------|-----|-------------------------------|-----|-----------------------------------|-----|-----------------------------------|-----|-------------------------------|-----|-----------------------------------|-----|-------------------------------|-----|-----------------------------------|-----|-------------------------------|-----|-------------------------------| | Total number of ASAP cases submitted | 72 | 37 | 50 | 94 | 37 | 72 | 100 | 103 | 42 | 88 | 695 | 11186 | | Percentage of eligible cases submitted | 84 | 45 | 57 | 90 | 41 | 80 | 93 | 90 | 88 | 85 | 75 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | 65 | 92 | 15 | 67 | 41 | 82 | 59 | 65 | 100 | 74 | 66 | 62 | | Spinal or epidural anaesthesia (%) | 2 | 54 | 53 | 36 | 60 | 67 | 35 | 12 | 41 | 70 | 75 | 50 | 40 | | Less than 10mg hyperbaric bupivacaine (%) | 3 | 2 | 5 | 0 | 0 | 0 | 0 | 2 | 0 | 0 | 1 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | 0 | 11 | 0 | 6 | 0 | 4 | 6 | 2 | 47 | 25 | 10 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | 23 | 56 | 43 | 29 | 48 | 17 | 40 | 64 | 32 | 31 | 38 | 33 | | Supplemental oxygen during spinal (%) | 6 | 88 | 25 | 64 | 67 | 57 | 83 | 70 | 85 | 91 | 80 | 71 | 62 | | Inhalational agent for GA induction (%) | 7 | 6 | 47 | 10 | 6 | 0 | 6 | 3 | 0 | 8 | 0 | 9 | 4 | | Spontaneous ventilation during GA (%) | 8 | 75 | 47 | 29 | 71 | 47 | 6 | 36 | 13 | 23 | 41 | 39 | 36 | | Nerve block provided (%) | 9 | 42 | 81 | 58 | 44 | 57 | 83 | 89 | 71 | 64 | 40 | 63 | 49 | | General and neuraxial not combined (%) | 10 | 97 | 94 | 100 | 100 | 92 | 100 | 97 | 100 | 100 | 99 | 98 | 97 | | Relative hypotension (%) | 11a | 83 | 97 | 92 | 86 | 68 | 89 | 94 | 90 | 68 | 88 | 85 | 88 | | Absolute hypotension (%) | 11b | 78 | 81 | 76 | 73 | 61 | 78 | 77 | 74 | 37 | 78 | 71 | 79 | | No suggestion of possible BCIS (%) | 12 | 83 | 94 | 74 | 100 | 75 | 88 | 77 | 77 | 88 | 86 | 84 | 87 | BOL. Royal Bolton Hospital

CMI. Cumberland Infirmary

COC. Countess of Chester Hospital

FAZ. University Hospital Aintree

FGH. Furness General

LGH. Leighton Hospital

MAC. Macclesfield District General Hospital

MRI. Manchester Royal Infirmary

NMG. North Manchester General Hospital

NOB. Noble’s Hospital

OHM. Royal Oldham Hospital

RLI. Royal Lancaster Infirmary

RLU. Royal Liverpool University Hospital

RPH. Royal Preston Hospital

SHH. Stepping Hill Hospital

SLF. Hope Hospital

SOU. Southport and Formby District General

TGA. Tameside General Hospital

TRA. Trafford General Hospital

VIC. Victoria Hospital

WDG. Warrington District General Hospital

WHI. Whiston Hospital

WIR. Arrowe Park Hospital

WYT. Wythenshawe Hospital

66

46

55

99

33

0

56

27

82

28

60

0

92

29

86

32

0

17

0

108

74

50

72

35 1309 11186

87

94

80

42

66

99

97

–

98

73

84 100 100

–

91

29 100

52

–

33

–

89

79

54

65

50

64

68

1

86

81

91

98

63

96 100

–

82 100

72

89

83

–

88

78

80

88

–

94

–

89

73

64

48

0

67

62

2 3

19 0

71 0

42 0

54 0

82 4

14 0

44 0

– –

65 0

48 0

52 0

31 0

37 0

– –

8 0

69 0

41 0

66 0

– –

94 0

– –

80 1

18 0

16 13

30 0

49 1

40 1

40 2

4 5

0 25

9 55

0 46

28 5

4 31

29 33

0 62

– –

2 26

23 14

0 60

14 56

3 36

– –

0 0

0 7

8 31

5 69

– –

0 23

– –

1 69

23 44

0 29

14 73

5 6

7 31

19 33

6

25

89

63

91

79 100

85

–

88

86

77

67

40

–

86

33

77

75

–

77

–

89

78

57

55

4

58

62

7

2

0

14

10

0

9

0

–

16

0

0

0

11

–

6

0

6

0

–

0

–

0

8

5

6

4

4

4

8

8

38

14

62

9

26

82

–

40

13

38

74

76

–

66 100

38

50

–

0

–

64

32

19

45

7

35

36

9 10

64 100

63 93

71 13 91 100

15 84 98 100

47 97

– –

33 96

59 96

40 90

48 81

48 90

– –

83 97

22 95

94 97

– –

24 100

– –

31 100

47 97

82 98

81 96

49 43

44 94

49 97

11a 11b 12

97 84 93

88 64 82

96 77 89

86 90 74 84 85 100

– – –

94 80 82

92 81 33

93 100 81 96 88 100

92 83 80

– – –

96 100 87 92 86 72 79 100 100

10 89 71

– – –

100 100 88

– – –

90 63 85

94 91 76 79 51 100

69 33 74 0 93 100

88 80 88

88 79 87

95 96 73 67 94 100

52 97

ASAP

BLA. Royal Blackburn Hospital 89

NORTH WEST

AEI. Royal Albert Edward Infirmary

© Healthcare Quality Improvement Partnership 2014. All rights reserved

73

National Hip Fracture Database: Anaesthesia Sprint Audit of Practice 2014

52 NORTH WEST Total number of ASAP cases submitted Percentage of eligible cases submitted Consultant/specialist anaesthetist and surgeon (%) Spinal or epidural anaesthesia (%) Less than 10mg hyperbaric bupivicaine (%) Fentanyl as intrathecal opioid (%) Sedation with midazolam or propofol during spinal (%) Supplemental oxygen during spinal (%) Inhalational agent for GA induction (%) Spontaneous ventilation during GA (%) Nerve block provided (%) General and neuraxial not combined (%) Relative hypotension (%) Absolute hypotension (%) No suggestion of possible BCIS (%)

| SOUTH CENTRAL | ASAP | |--------------|------| | HOR: Horton General Hospital | 47 | | IOW: St Mary’s Hospital Newport | 0 | | MKH: Milton Keynes General Hospital | 62 | | NHH: North Hampshire Hospital | 37 | | QAP: Queen Alexandra Hospital | 125 | | RAD: John Radcliffe Hospital | 111 | | RBE: Royal Berkshire Hospital | 82 | | RHC: Royal Hampshire County Hospital | 59 | | SGH: Southampton General Hospital | 78 | | SMV: Stoke Mandeville Hospital | 24 | | WEX: Wexham Park Hospital | 63 | | SOUTH CENTRAL | 688 | | ASAP | 11186 |

| Total number of ASAP cases submitted | 47 0 62 37 125 111 82 59 78 24 63 688 11186 | | Percentage of eligible cases submitted | 81 – 86 77 70 78 86 91 52 27 85 67 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 66 – 79 76 61 57 68 55 47 44 68 56 62 | | Spinal or epidural anaesthesia (%) | 2 36 – 21 70 60 57 18 57 54 50 38 42 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 0 – 0 0 0 0 0 0 11 3 1 2 | | Fentanyl as intrathecal opioid (%) | 4 18 – 47 65 13 70 47 11 10 11 23 29 19 | | Sedation with midazolam or propofol during spinal (%) | 5 54 – 53 85 82 26 11 67 27 0 38 40 33 | | Supplemental oxygen during spinal (%) | 6 92 – 40 85 84 44 67 82 78 100 54 66 62 | | Inhalational agent for GA induction (%) | 7 7 – 2 0 8 0 3 5 8 0 0 3 4 | | Spontaneous ventilation during GA (%) | 8 33 – 45 36 51 39 27 15 24 67 73 37 36 | | Nerve block provided (%) | 9 87 – 69 49 52 38 78 67 53 58 65 56 49 | | General and neuraxial not combined (%) | 10 100 – 95 100 99 98 99 98 97 100 95 98 97 | | Relative hypotension (%) | 11a 96 – 89 43 86 92 91 95 55 29 89 79 88 | | Absolute hypotension (%) | 11b 84 – 77 90 76 77 91 80 85 83 70 83 79 | | No suggestion of possible BCIS (%) | 12 71 – 79 90 92 100 100 96 100 86 92 91 87 | | SOUTH EAST COAST | ASAP | |-----------------|------| | Total number of ASAP cases submitted | 0 95 73 55 31 86 110 117 56 37 78 0 76 102 916 11186 | | Percentage of eligible cases submitted | – 88 92 44 29 98 92 90 82 44 78 – 67 77 63 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 – 80 71 87 52 74 87 77 39 72 92 – 57 89 63 62 | | Spinal or epidural anaesthesia (%) | 2 – 63 66 13 61 60 25 78 20 25 74 – 73 42 43 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 – 12 0 0 0 7 3 76 0 0 0 – 0 19 8 2 | | Fentanyl as intrathecal opioid (%) | 4 – 1 29 0 16 13 3 37 0 13 0 – 15 10 10 19 | | Sedation with midazolam or propofol during spinal (%) | 5 – 53 42 43 71 70 32 49 27 75 40 – 41 14 40 33 | | Supplemental oxygen during spinal (%) | 6 – 73 78 86 86 67 82 100 73 75 89 – 41 76 66 62 | | Inhalational agent for GA induction (%) | 7 – 0 0 2 9 0 0 0 2 0 0 – 5 20 3 4 | | Spontaneous ventilation during GA (%) | 8 – 57 50 74 73 35 90 58 44 38 36 – 40 33 45 36 | | Nerve block provided (%) | 9 – 38 34 93 58 39 72 50 59 62 28 – 16 66 44 49 | | General and neuraxial not combined (%) | 10 – 95 100 100 100 88 100 99 91 100 97 – 100 98 98 97 | | Relative hypotension (%) | 11a – 83 84 87 87 86 92 69 96 55 70 – 86 94 85 88 | | Absolute hypotension (%) | 11b – 77 57 71 70 83 92 45 92 72 81 – 77 81 78 79 | | No suggestion of possible BCIS (%) | 12 – 100 61 89 73 97 84 98 79 100 85 – 89 80 88 87 | | SOUTH WEST | ASAP | |------------|------| | Total number of ASAP cases submitted | 34 86 0 110 110 45 81 216 132 101 144 127 65 113 81 36 62 1543 11186 | | Percentage of eligible cases submitted | 25 87 – 94 90 46 94 95 89 94 92 82 81 96 100 44 81 76 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 30 35 – 94 90 46 94 95 89 94 92 82 81 96 100 44 81 76 68 | | Spinal or epidural anaesthesia (%) | 2 58 26 – 9 51 53 12 21 43 74 40 37 25 69 33 31 21 36 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 0 0 – 0 1 0 4 5 3 1 1 0 10 0 0 0 1 2 | | Fentanyl as intrathecal opioid (%) | 4 0 0 – 15 9 4 24 17 3 25 7 4 10 2 9 0 15 8 19 | | Sedation with midazolam or propofol during spinal (%) | 5 77 32 – 33 26 33 36 24 50 54 29 63 67 48 59 50 20 41 33 | | Supplemental oxygen during spinal (%) | 6 62 79 – 83 34 67 55 64 82 74 75 38 73 95 70 88 80 66 62 | | Inhalational agent for GA induction (%) | 7 0 2 – 1 0 4 6 2 1 0 5 0 0 0 15 4 2 4 | | Spontaneous ventilation during GA (%) | 8 50 32 – 25 73 48 46 47 71 41 51 82 41 69 48 37 80 50 36 | | Nerve block provided (%) | 9 56 68 – 76 31 47 48 76 50 17 41 38 70 23 74 56 73 48 49 | | General and neuraxial not combined (%) | 10 97 99 – 95 82 96 84 92 94 98 83 75 92 86 100 94 95 92 97 | | Relative hypotension (%) | 11a 88 69 – 86 86 93 93 88 91 80 95 85 87 85 95 44 100 86 88 | | Absolute hypotension (%) | 11b 78 76 – 85 86 73 91 84 72 69 85 79 76 82 90 73 95 82 79 | | No suggestion of possible BCIS (%) | 12 94 66 – 75 87 91 68 83 87 92 86 79 94 47 81 90 82 82 87 | | WALES | BRG. Bronglais General Hospital | CLW. Glan Clwyd DGH Trust | GWE. Royal Gwent Hospital | GWY. Ysbyty Gwynedd Hospital | MOR. Morriston Hospital | NEV. Nevill Hall Hospital | PCH. Prince Charles Hospital | POW. Princess Of Wales Hospital | RGH. Royal Glamorgan | UHW. University Hospital of Wales | WRX. Maelor Hospital | WWG. West Wales General | WYB. Withybush General Hospital | WALES | ASAP | |-------|--------------------------------|-----------------------------|---------------------------|-----------------------------|------------------------|--------------------------|-----------------------------|-----------------------------|------------------------|-----------------------------|------------------------|-----------------------------|-----------------------------|-------|------| | Total number of ASAP cases submitted | 16 | 67 | 64 | 58 | 132 | 64 | 71 | 69 | 48 | 54 | 50 | 0 | 50 | 743 | 11186 | | Percentage of eligible cases submitted | 70 | 72 | 74 | 81 | 94 | 97 | 96 | 92 | 94 | 41 | 82 | – | 98 | 76 | 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 | 100 | 95 | 50 | 98 | 18 | 86 | 83 | 81 | 40 | 38 | 86 | – | 88 | 66 | 62 | | Spinal or epidural anaesthesia (%) | 2 | 44 | 47 | 56 | 25 | 21 | 44 | 64 | 10 | 29 | 47 | 38 | – | 34 | 35 | 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 | 14 | 0 | 0 | 0 | 4 | 0 | 2 | 0 | 6 | 0 | 5 | – | 0 | 2 | 2 | | Fentanyl as intrathecal opioid (%) | 4 | 43 | 0 | 14 | 71 | 39 | 60 | 56 | 33 | 71 | 46 | 0 | – | 39 | 36 | 19 | | Sedation with midazolam or propofol during spinal (%) | 5 | 40 | 4 | 31 | 25 | 8 | 22 | 27 | 20 | 14 | 62 | 20 | – | 15 | 22 | 33 | | Supplemental oxygen during spinal (%) | 6 | 100 | 58 | 78 | 75 | 76 | 57 | 77 | 80 | 29 | 76 | 90 | – | 92 | 68 | 62 | | Inhalational agent for GA induction (%) | 7 | 22 | 3 | 3 | 0 | 2 | 0 | 4 | 10 | 0 | 7 | 0 | – | 15 | 5 | 4 | | Spontaneous ventilation during GA (%) | 8 | 22 | 29 | 34 | 24 | 41 | 33 | 21 | 28 | 56 | 41 | 39 | – | 33 | 31 | 36 | | Nerve block provided (%) | 9 | 38 | 61 | 61 | 45 | 80 | 45 | 39 | 90 | 67 | 72 | 58 | – | 88 | 57 | 49 | | General and neuroaxial not combined (%) | 10 | 100 | 100 | 98 | 100 | 100 | 99 | 99 | 100 | 100 | 98 | – | 100 | 100 | 97 | | Relative hypotension (%) | 11a | 40 | 97 | 97 | 100 | 94 | 94 | 87 | 85 | 85 | 100 | 90 | – | 94 | 89 | 88 | | Absolute hypotension (%) | 11b | 40 | 81 | 87 | 88 | 88 | 88 | 78 | 78 | 74 | 90 | 78 | 60 | – | 86 | 79 | 79 | | No suggestion of possible BCIS (%) | 12 | 100 | 70 | 67 | 89 | 86 | 62 | 100 | 100 | 100 | 83 | 74 | – | 53 | 83 | 87 | | WEST MIDLANDS | ASAP | |---------------|------| | Total number of ASAP cases submitted | 57 64 80 67 85 49 100 14 74 120 64 0 127 0 126 0 0 85 1112 11186 | | Percentage of eligible cases submitted | 83 51 86 78 83 86 26 81 98 68 – 84 – 96 – – 77 61 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 89 53 95 88 80 90 55 29 78 85 77 – 30 – 26 – – 71 53 62 | | Spinal or epidural anaesthesia (%) | 2 25 25 30 73 26 69 26 36 33 67 73 – 13 – 31 – – 56 32 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 0 0 0 7 5 0 3 0 3 6 2 – 5 – 2 – – 2 2 2 | | Fentanyl as intrathecal opioid (%) | 4 81 13 14 4 10 78 16 60 12 54 64 – 0 – 79 – – 2 2 2 | | Sedation with midazolam or propofol during spinal (%) | 5 75 33 27 19 35 27 29 0 46 25 27 – 46 – 41 – – 29 26 33 | | Supplemental oxygen during spinal (%) | 6 17 47 68 87 76 76 35 33 50 82 75 – 54 – 59 – – 71 46 62 | | Inhalational agent for GA induction (%) | 7 2 11 4 0 12 7 4 0 11 0 0 – 9 – 9 – – 3 4 4 | | Spontaneous ventilation during GA (%) | 8 88 41 46 65 12 43 26 88 72 61 12 – 73 – 41 – – 78 41 36 | | Nerve block provided (%) | 9 91 73 70 31 64 65 72 64 51 57 28 – 56 – 83 – – 47 65 49 | | General and neuraxial not combined (%) | 10 100 98 99 95 100 100 98 100 90 96 100 – 98 – 100 – – 94 98 97 | | Relative hypotension (%) | 11a 95 92 89 92 93 87 92 93 91 81 80 – 91 – 91 – – 100 93 88 | | Absolute hypotension (%) | 11b 93 77 86 80 77 80 79 71 78 68 84 – 85 – 73 – – 80 84 79 | | No suggestion of possible BCIS (%) | 12 100 67 100 66 92 89 80 50 78 84 84 – 90 – 78 – – 91 86 87 | | YORKSHIRE AND THE HUMBER | ASAP | |--------------------------|------| | Total number of ASAP cases submitted | 71 61 57 19 34 58 58 0 113 103 121 143 78 68 46 81 1111 11186 | | Percentage of eligible cases submitted | 96 91 70 39 31 84 89 – 95 71 86 90 96 100 82 82 75 68 | | Consultant/specialist anaesthetist and surgeon (%) | 1 79 75 60 79 100 78 68 – 67 48 87 73 87 96 87 52 71 62 | | Spinal or epidural anaesthesia (%) | 2 52 52 64 95 62 29 49 – 79 49 80 68 77 47 72 56 58 40 | | Less than 10mg hyperbaric bupivicaine (%) | 3 0 0 3 0 10 0 0 – 5 0 0 7 8 3 0 4 2 2 | | Fentanyl as intrathecal opioid (%) | 4 69 0 6 0 10 21 3 – 51 4 36 28 2 8 6 0 15 19 | | Sedation with midazolam or propofol during spinal (%) | 5 6 36 32 69 45 60 48 – 9 35 59 68 36 29 14 59 38 33 | | Supplemental oxygen during spinal (%) | 6 88 59 71 69 64 60 56 – 76 86 62 74 82 24 71 68 63 62 | | Inhalational agent for GA induction (%) | 7 11 0 0 0 20 21 – 27 6 8 4 12 0 0 3 7 4 | | Spontaneous ventilation during GA (%) | 8 31 7 43 0 46 27 55 – 41 44 71 76 59 40 33 66 40 36 | | Nerve block provided (%) | 9 51 40 51 5 65 59 54 – 36 49 64 75 31 21 48 36 43 49 | | General and neuraxial not combined (%) | 10 99 100 98 100 100 100 98 – 97 97 100 99 97 99 98 96 99 97 | | Relative hypotension (%) | 11a 93 88 95 100 100 100 88 – 85 76 91 88 88 84 86 88 91 88 | | Absolute hypotension (%) | 11b 83 67 85 63 79 86 70 – 66 59 61 68 65 80 64 75 73 79 | | No suggestion of possible BCIS (%) | 12 90 88 100 83 83 78 91 – 85 79 88 93 88 60 100 88 87 87 | References

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